Pediatric Trauma

Fractures in children can occur due to accidents, child abuse or due to some pathologies. Motor vehicle accidents and falls from a height account for major mechanisms of accidental trauma causing fractures in children.

Some fractures are known to occur more in specific age groups. For example, fractures of the femur are most common in children ages 0 to 3 years of age. Similarly, fractures of supracondylar area in humerus are more common in second decade and peak is around 7 years of age.

In children, upper limb is injured much more commonly than the lower limb. Distal radius is most common fracture in uppper limb followed by elbow.

Physeal injuries constitute 14.5% – 27.6% of pediatric injuries. Open fractures constitute about 3% of the injuries are open fractures

Multiple fractures in children are uncommon.

Epidemiology of Fractures in Children

Incidence

42% of the boys and 27% of the girls sustain at least one fracture from 0 to 16 years of age.

Each year 1.6% to 2.1% of all the children sustain a fracture.

About 18% of children out of all children with injury, would have a fracture.

Fractures show a linear increase with age , peaking at 12 years and then decrease until age of 16 years

Type of Trauma

Nonaccidental trauma [Child abuse] is the leading cause of fractures during the first year of life. In later years accident is.

Gender

Boys are affected almost 3 times more than girls for a single fracture. However, in some areas there is little difference in the incidence of fractures between boys and girls.

Role of Behavior

Boys had a higher number of injuries in pedestrian/auto injuries but the trend is changing as more and more girls are showing increased participation in physical activities.

Right/Left

Left upper extremity demonstrates a slight but significant predominance in most of the reports.

Seasonal Variations

Fractures are more common during the summer. This is due to the fact that length of the day increases and physical activity is more.

But this does not apply to small children and infants, whose activities do not depend on the season. There appears to be no significant seasonal influence.

Changing Trends

Increase in Minor Trauma

Increased participation in sports has resulted in increase in some types of fractures in children, for example – fracture of shaft of femur. Moreover, there is increased awareness and better availability of medical facilities, minor injuries are reported more than before.

Child Abuse

The number of fractures due to non-accidental causes has risen consistently in the past and the increase has been reported as high as 150 times.

Treatment of Fractures in Children

Initial Management of Injured Child

First priority in an injured child management of the life-threatening,injuries if present.

As in trauma management, care of airway, breathing and circulation takes precedence followed by cervical spine stabilization.

Fluid replacement is done to compensate the loss from hemorrhage, initially with intravenous crystalloid solution.

In very young children where rapid intravenous access may be difficult, intraosseous fluid infusion through tibia may be considered using an intraosseous route.

Death is common if hypovolemic shock is not rapidly reversed but excessive fluid replacement also may lead to interstitial pulmonary edema. A urinary catheter is essential during the resuscitation to monitor urine output and to gauge adequate organ perfusion.

Evaluation

After the initial resuscitation and stabilization, the child is assessed from head to toe and injuries in the head, face, cervical spine, chest, abdomen, pelvis, spine and extremities.

If an extremity is injured, note should be made if the injury is closed or open. Any active bleeding should be stopped by pressure bandage.

Imaging Studies

Radiographs

After the initial resuscitation and physical examination, xrays are done. Any limb with a significant injury should be examined on x-ray. In presence of head injury or suspected neck injury, a lateral cervical spine x-ray is obtained.

Computed Tomography

Computed tomography is essential in a child with multiple injuries.

Ultrasound

Ultrasound is very helpful in abdominal injuries. It is very accurate means for detecting hemoperitoneum following injury. But ultrasound reporting is dependent on operator and in comparison CT is superior for diagnosing visceral injury in children.

Magnetic Resonance Imaging

Primary use of the Magnetic resonance imaging is for the detection of injury to the brain or the spine and the spinal cord. In SCIWORA syndrome, MRI demonstrates the site and extent of spinal cord injury and in defining the level of injury to the disks or vertebral apophysis.

MRI also is very useful in evaluating knee injuries that cannot be visualized on routine x-rays.

Treatment

Life threatening injuries are priority. Splinting of the fractures will generally suffice as the initial management.

After the child is stabilized, the management of orthopedic injuries is done depending on the type of injury.

Classically, fractures in children were treated with non operative treatment. With evolution of orthopedics and improvement in surgical techniques, availability of C-arm image intensifier more and more fractures see increased operative management.

One of the major advances in orthopedics is surgical techniques that allow to fix the fractures with percutaneous methods. Children tolerate all types of casts well for short periods of time, which allows a minimally stabilized fracture to be immobilized with a cast until there is sufficient internal callous.

Perfect expectation of modern parents often direct the treating physician toward operative intervention.

Actual treatment of the fracture depends on site of fracture, age and body habitus of the child, expectation of the parents and concomitant injuries. Treatment of individual fractures is discussed separately.

Greenstick Fracture Definition

A greenstick fracture typically occurs in children. Greenstick fractures are incomplete fractures of long bones and are commonly mid-diaphyseal. Forearm bones [radius, ulna] and leg bones are commonly affected.

The fractures typically affect the forearm and lower leg.

Greenstick fracture occurs when the force applied to a bone results in bending of the bone and breaks the bone on convex aspect of the bend but does not extend the break to concave surface. The bones of children are soft and are covered with thick fibrous periosteum of immature bone.

The situation is similar to bending a soft green branch of tree [stick]. If you hold a green branch or stick and bend it, it would bend only till some time. If further force is applied, the stick would break on the convex surface.

Greenstick fracture does occur in similar manner when a bending force acts on the bone, one of the cortex bends whereas other breaks.

Signs and Symptoms of Greenstick Fracture

A greenstick fracture would cause pain at the injured area. The area may be swollen and either red or bruised and there could be a visible deformity. Older child may guard the area. Younger children may present with crying only.

Imaging of Greenstick Fracture

Anteroposterior and lateral xrays of the affected part are standard imaging for a greenstick fracture. The xrays would reveal site and deformity of the fracture.

Greenstic Fracture Treatment

The treatment includes reduction of the fracture, which may include overcorrection [completing of the fracture]. In case the angulation is minimal, correction may not be required.

After reduction, three point molding is done to keep tension on intact periosteal hinge. A long arm cast is applied and kept for a period of four to six weeks.

In infants, angulation up to up to 30 degrees is acceptable. In older children up to 15 degrees of angulation may be acceptable depending on age of the patient.

Supracondylar fractures of humerus are very common injuries in children. These injuries frequently result when the child falls on outstretched hand.

Supracondylar region in children is weaker in children as the part is growing.

Image 1 – AP and Lateral View Xray of Supracondylar Fracture Humerus

Suprcondylar fracture of humerus AP & lateral views.

The xrays in the picture are anteroposterior and lateral views of elbow of seven year old child who sustained injury after he fell from a tree.

The fracture in present image was successfully treated non operatively.

Image 2 – Xray of Supracondylar Fracture Humerus in Malposition in a Child

Supracondylar fractures are very common childhood injuries. Most of the fractures can be treated by conservative means. Severely displaced fractures are treated by closed reduction and percutaneous pinning.

This Supracondylar Fracture Is Not In Acceptable Position

The image shows a child’s elbow in a plaster having a suprcondylar fracture which is rotated and malpositioned.

Supracondylar factures are very common fractures of children. Most of these are extension type injuries where the distal fragment of the fracture goes into extension as compared to proximal part. This type of injury constitutes about 95% of the injury. Other 5% is type where the distal fragment goes into flexion.

Following xrays are of a seven year old male child who suffered flexion type of supracondylar injury to his right humerus

Flexion Type of Supracondylar Fracture – Lateral View

Note that in lateral view the distal fragment has moved volar as compared to proximal fragment.

Flexion Type of Supracondylar Fracture – Lateral View

These fractures are reduced and held in position of elbow extension. Neurovascular deficit as usual should be carefully examined.

Child injury rate due to falling television is on the rise. A new study published in journal Pediatrics has reported that in past 22 years rate of child injury from falling televisions has increased by 95%.

The study by Roo and colleagues spans a period from 1990 to 2011 and is published on 22 July , online.

the average annual injury rate attributable to televisions in children was 2.43 per 10,000 children younger than 18, according to Gary Smith, MD, of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and colleagues.

Prehospital care involves initial recognition and treatment of life-threatening injuries at first contact with patient.This may mean roadside examination and intervention in transporting ambulance.

After discovery of Golden Hour [ Victim’s chances of survival are greatest if they receive care within a short period of time after a severe injury], it was thought to provide the care to victim at first contact, wherever the victim may be.

Because substantial time is lost between transportation of the patient, concept of prehospital trauma care was developed. Basic aim is to recognize the injuries and intervene if necessary, enroute to the hospital.

Greek military operations show the earliest records of organized prehospital trauma care, including the advent of triage. [Triage is prioritizing the injury victims according to severity of injury.]

After the injuries have been recognized, the patient is evacuated to a center with adequate resources for definitive care.

Prehospital trauma care team may vary depending on the response needed, which in turn would depend on severity of the disaster. Prehospital trauma care can include just basic first responders or joined by paramedics and physicians.

Techniques have been developed to safely extricate injured patients from crumpled vehicles, damaged structures, and precarious geographic regions.

In a trauma victim, the order of priorities can be remembered as ABCDE. They are prioritized depending on the severity of the element and urgency to deal with it. Here is brief of what each letter signifies.

A—Airway

First priority is to confirm and establish a secure unobstructed airway.

85% of trauma patients are estimated to die of airway problems before they reach the hospital. Airway management is particularly critical following head injury, cervical spine, or thoracic trauma and takes precedence over other things including transportation [unless it can be done en route]

Orotracheal intubation, either with or without sedatives and paralytics, is the mainstay for airway management.

Other options are

Bag-valve-mask ventilation with jaw lift

Oral or nasal airway

Esophagotracheal combitube

Laryngeal mask airway

Nasotracheal intubation

Percutaneous needle, or open cricothyrotomy.

B—Breathing

Breathing is an activity responsible for dispensing oxygen to the lungs which then gets exchanged and is transported to the tissues. Breathing is next management priority after airway.

If the patient is awake, cooperative and has been found to have a stable airway, oxygen by face mask should suffice. However, the patient should be monitored closely for airway and ventilation.

Pulse oximetry is used for measuring oxygen hemoglobin saturation levels in prehospital patients and can guide on adequacy of breathing and ventilation.

One of the important aspect of prehospital management is recognition of life threatening injuries such as pneumothorax [air in thoracic cavity], pneumohemothorax [air and blood in cavity] and hemothorax [blood in thoracic cavity].

Along with hemothorax and flail chest, pneumothorax remains a significant cause of prehospital death.

Needle thoracostomy is the first line treatment for suspected tension pneumothorax.

C—Circulation

Any major loss of circulation is dealt with and fluid resuscitation is done through intravenous access, fluid treatment, drug administration, and earlier access for transfusion upon arrival to the hospital.

Undress patient and look for injury. Extra information about patient that matters comes under this. If the patient is suspected of having a neck or spinal injury, in-line immobilization is important.

In the field, “E” stands for extra information like procedures performed and environmental protection (e.g., protect the patient from extremes of heat or cold), whereas in advanced life support, E stands for exposure and environmental control, meaning completely undress the patient, visualize all body surface areas, but prevent hypothermia.

Injury Severity Score is based on Abbreviated Injury Scale and is used in assessment of injury in adults an children both. It along with pediatric trauma score are quite reliable in predicting injury measure in children.

Abbreviated Injury Scale is an anatomical scoring system where injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe, and 6 a nonsurvivable injury.

The objective of Abbreviated Injury Scale is to gauge threat to life associated with an injury and is not meant to represent a comprehensive measure of severity.

Detailed scoring is done as follows

Minor – 1

Moderate – 2

Serious – 3

Severe – 4

Critical – 5

Unsurvivable – 6

Injury Severity Score

The Injury Severity Score is an anatomical scoring system that provides an overall score for patients with multiple injuries to measure the injury.

Each injury is assigned an abbreviated injury score and is allocated to one of six body regions

Head

Face

Chest

Abdomen

Extremities including Pelvis

External

Out of these 6 areas, 3 most severely injured body regions are chosen and have their score squared and added together to produce the ISS score.

An example of the ISS calculation is shown below

Region

Injury Description

AIS

Square(Top Three)

Head & Neck

Cerebral Contusion

3

9

Face

No Injury

0

–

Chest

Flail Chest

4

16

Abdomen

Minor Contusion of LiverComplex Rupture Spleen

25

25

Extremity

Fractured femur

3

–

External

No injury

0

–

Total Injury Severity Score = 9+16+25=50

Maximum possible injury severity score is 75 and minimum 0.

If an injury is assigned an Abbreviated Injury Score of 6 (unsurvivable injury), the Injury Severity Score is automatically assigned to 75.

Pediatric trauma score is a score used in pediatric injuries to gauge vulnerability of the injured child to traumatic injury.

The score uses following parameters

Weight of the child

Airway status

Systolic BP

Consciousness Level

Type of fractures

Type of Wound

Following table shows how to calculate score for each parameter-

Score

+2

+1

-1

Weight

>20Kgs

10-20Kgs

<10 kgs

Airway

Patent

Maintainable

Unmaintainable

Systolic BP

>90mm Hg

50-90 m Hg

<50 mm Hg

CNS

Awake

Loss of consciousness

Unresponsive

Fractures

None

Closed or suspected

Multiple closed or open

Wounds

None

Minor

Major, penetrating or Burns

Final score is the sum total of all the scores.

The minimal score is -6 and the maximum score is +12.

Pediatric trauma score has been found to be a valid and reliable tool in predicting mortality of an injured child.

If pediatric trauma score is >8, mortality is about 9%

If pediatric trauma score is <0, mortality is 100%

Moreover, there is a linear relationship between the decrease in pediatric trauma score and mortality risk.

A clear and concise communication between the pre-hospital system and the hospital center is essential. This communication should be both simple and as detailed as possible in describing the patient’s state. The Pediatric Trauma Scale meets these criteria.

Child abuse is defined as maltreatment of a child by either parents or caretakers, and includes physical, sexual, and emotional abuse, as well as emotional and physical neglect. Child abuse, in itself is a huge subject and involves many factors. For the scope of this website we are restricting our discussion to physical form of the abuse.

Incidence of Child Abuse

The incidence of physical abuse in America is estimated to be 4.9 children per 1,000, and 1 of every 1,000 abused children die.

30% to 50% of abused children require orthopedic care.

The children who are returned to their homes after an unrecognized episode of child abuse have a 25% risk of serious reinjury and a 5% risk of death.

Risk Factors For Child Abuse

Home At Risk For Child Abuse

Households with following situations are at higher risk for child abuse

Marital separation

Job loss

Divorce

Family death

Housing difficulties

Financial crisis are more likely to have abusive episodes

Families with two unplanned births

History of abuse of the parents in their childhood.

High levels of parental stress

High belief in the worth of corporal punishment

Parental substance abuse

Young, unmarried mother

Violence in the home

The Child at Risk for Child Abuse

Children younger than 3 years of age.

First-born children

Premature infants

Stepchildren

Handicapped children

Mother Profile that increases risk of child abuse

Age <20 years

Lower educational achievement

History of sexual abuse

Child guidance issues

Absent father during childhood

History of psychiatric illness

Father profile that increases risk of child abuse

Age <20 years

Lower educational achievement

Child guidance issues

History of psychiatric illness

General

Parent history of child abuse

Divorce or separation of mother’s parents

Maternal history of being separated from mother, parental alcohol or drug abuse

Maternal history of depression

Physical Effects of Child Abuse

Depending on the degree of assault or injuries suffered, the effects of abuse can be minor or major.

It may result in minor bruises or major fractures. Rib fractures which are otherwise very uncommon in children are commonly seen in child abuse victims.

Shaken baby syndrome results from violent shaking of the baby and in 80% of cases results in permanent neurological damage or death in 30% of cases.

In this injury, damage may result from increased pressure in the skull, bleeding in the brain, damage to the spinal cord and neck, and fractures

Child abuse leads to impaired brain development and long-term consequences for . Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers.

Warning Signs of Physical Abuse in Children

Frequent injuries or unexplained bruises, welts, or cuts.

Is always watchful and “on alert,” as if waiting for something bad to happen.

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